GIS 11 MA/025: Managed Care Enrollees with Medicare

To: Local District Commissioners, Medicaid Directors

From: Jason A. Helgerson, Medicaid Director and Deputy Commissioner - Office of Health Insurance Programs

Subject: Managed Care Enrollees with Medicare

Effective Date: Immediately

Contact Person: Managed Care County Representative (518)473-1134

The Mainstream Medicaid managed care program, as well as Family Health Plus excludes from enrollment consumers who receive Medicare benefits. Family Health Plus eligibility is lost once Medicare coverage is gained and in MMC the recipient must be disenrolled from the plan as soon as possible (prospectively). Enrollment for Medicare beneficiaries is only allowed for Medicaid Advantage, Medicaid Advantage Plus and Managed Long Term Care products.

Recent audits have indicated that many Medicare recipients are not being disenrolled from managed care plans in a timely manner. The result is that plans have to cover ineligible consumers and NYS pays premiums that the plans would not be entitled to if the disenrollment had taken place.

Enrollment broker districts have a Medicare "sweep" process to disenroll those who are excluded from Medicaid managed care when eMedNY shows Medicare on the file. Family Health Plus is not part of this process, as it requires an eligibility review.

To prevent inappropriate managed care capitation payments, LDSS must follow the following procedures:

  • For Medicaid managed care, promptly identify all inappropriate managed care enrollees with Medicare via the resources below.
  • LDSS should disenroll Medicare recipients prospectively as soon as possible, according to pulldown.
  • The consumer must be noticed, with Fair Hearing rights that he is being disenrolled because of the exclusion.

For Family Health Plus enrollees with Medicare, LDSS must do a redetermination of the consumer's Medicaid eligibility. FHP consumers who lose their eligibility must receive a closing notice; those transitioned to Medicaid must receive an undercare notice updating the consumer's eligibility.

As an excluded population, Medicaid managed care enrollees with Medicare are not entitled to managed care guarantee coverage. However, FHP enrollees who have Medicare coverage are entitled to a guarantee period.

Resources to identify Managed Care/FHP enrollees with Medicare:

  • Monthly Rosters
  • Mobius Report BM55200-R0010 (MAMC/TPHI Monthly Report)
  • BICS Report 001-x-99* wmsbmcde (Dually Eligible Report) *99 replaced by County Code
  • Mobius Report TRMP0069 – TPL Medicare Warning Report
  • Plan report and documentation of Medicare